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			<h3>My Health History:</h3>
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					<span style="font-weight:bold">Are you pregnant or breast feeding?</span>
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					<input type="checkbox" name="chkBxPregnant1" value="yes"/>Yes<br/>
					<input type="checkbox" name="chkBxPregnant2" value="no"/>No<br/>
				    <input type="checkbox" name="chkBxPregnant3" value="I do not know"/>I do not know<br/>
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					<label for="weight" style="width: 330px;">What medications are you currently taking?</label>
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					<label for="vitamin" style="width: 330px;">What vitamins are you currently taking?</label>
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					<label for="supplement" style="width: 330px;">What supplements are you currently taking?</label>
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					<span style=" font-weight: bold">What surgeries have you gone through in the <br/><span style="padding-left: 290px;">past?</span></span>
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				<li style="padding-left: 100px;">					
					<input type="checkbox" name="chkBxMedication" value="medication"/>I am not taking any medications, vitamins, or supplements<br/>
					<input type="checkbox" name="chkBxSurgeries" value="surgeries"/>I have not had any surgeries<br/>
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					<span style="font-weight:bold">Have you been diagnosed as having any of the following conditions? (check all that apply):</span>
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					<input type="checkbox" name="chkBxArthritis" value="arthritis"/>Arthritis<br/>
					<input type="checkbox" name="chkBxCancer" value="cancer"/>Cancer<br/>
					<input type="checkbox" name="chkBxDiabetes" value="diabetes "/>Diabetes <br/>
					<input type="checkbox" name="chkBxDyslipidemia" value="dyslipidemia"/>Dyslipidemia<br/>
					<input type="checkbox" name="chkBxHiv" value="hiv"/>HIV<br/>
					<input type="checkbox" name="chkBxHypertension" value="hypertension"/>Hypertension<br/>
					<input type="checkbox" name="chkBxMetabolic" value="metabolic-syndrome"/>Metabolic syndrome<br/>
					<input type="checkbox" name="chkBxOverweight" value="overweight"/>Overweight/Obese<br/>
					<input type="checkbox" name="chkBxOsteoporosis" value="osteoporosis"/>Osteoporosis<br/>
					<input type="checkbox" name="chkBxPeripheral" value="peripheral "/>Peripheral Artery Disease<br/>
					<input type="checkbox" name="chkBxPulmonary" value="pulmonary"/>Pulmonary Disease<br/>
					<input type="checkbox" name="chkBxRenal" value="renal"/>Renal Disease<br/>
					<input type="checkbox" name="chkBxOther" value="other"/>Other - Please specify:&nbsp;
				    <input id="txtOtherGoals" type="text" />
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				<button class=" awesomebtn green" title="My Health Risk Factors" onclick="location.href='health-risk-factors1.html'">Continue &raquo;</button>		
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